Pensioner died after ‘test result was left on doctor's desk for six days'

A PENSIONER died after a scan result was left on a doctor’s desk for six days.

Trevor Reynolds, 78, of Abergele, North Wales, had a CT scan which revealed a life-threatening blood clot.

His results were left on the desk of consultant oncologist Dr Angel Garcia-Alonso on a Thursday – but he was on a long weekend off with annual leave.

The inquest heard Dr Garcia-Alonso only saw the scan when he returned on the Wednesday after the break.

But tragically, retired lorry driver Mr Reynolds died three days later.

The coroner said it was likely that Mr Reynolds would not have died on 15 May 2021 had his scan been acted upon when reported.

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Dr Garcia-Alonso said: "Had I seen it, I would have alerted the GP and the patient and got the patient in and on anticoagulation [blood clot prevention medication] as soon as possible.

When asked by the coroner if the delay had been a disadvantage in the likely success of treatment, he said: "Yes, it has played a part in the outcome."

Mr Reynolds' widow Maureen said: "I am still distressed and I'll never get over it.

"I just hope now that they will get something done and other people won't have to go through what me and my family has gone through. It's horrible."

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Mr Reynolds was being treated for cancer of the oesophagus at Ysbyty Glan Clwyd hospital in Bodelwyddan, North Wales.

On 6 May last year Consultant radiologist Dr Phillip Travis gave his report to his secretary.

The secretary in turn passed it to Dr Garcia-Alonso's secretary, who placed it on his desk where it remained unopened for days.

Mr Reynolds was immediately placed on a course of treatment when the discovery was made.

But he died on 15 May from a blood clot and pneumonia.

Coroner for North Wales East and Central John Gittins recorded a narrative conclusion at the inquest. 

He said: "The evidence indicated that had treatment for the clot began sooner there would have been a better prospect of it being successful and further that the treatment of his cancer had been effective.

"On the balance of probabilities therefore it is likely that Mr Reynolds would not have died on the 15th of May 2021 if the result of his scan had been acted upon when reported by the radiologist on the 6th of May."

Hospital administration manager Ellen Ruth Davies said the procedure for passing on urgent results was now more "robust".

These include making sure other senior clinicians can be contacted if a consultant is not available to be made aware of urgent cases.

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Mr Gittins said he was "disappointed" these changes had not been formally adopted until December – seven months after the “awful event” of Mr Reynolds' death.

He was "dumbfounded" to hear the new system was only now being audited to see whether the new changes were working.

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